Nursing > Questions and Answers > FOCUSED EXAM: CHEST PAIN Objective Data Collection

FOCUSED EXAM: CHEST PAIN Objective Data Collection

Inspected face 1 of 1 point Appearance (1/1 point)  No visible abnormal findings  Rash or lesion  Cyanosis  Pallor  Redness or flushing  Evidence of trauma (scar, laceration, or bruising) Inspected for jugular venous distension 1 of 1 point Height Of Venous Pressure (1/1 ... point)  4 cm or less above the sternal angle  More than 4 cm above the sternal angle Inspected chest 1 of 1 point Symmetry (1/2 point)  Symmetric  Asymmetric Appearance (1/2 point)  No visible abnormal findings  Rash or lesion  AP diameter abnormal  Intercostal retraction while breathing  Excessive use of accessory muscles while breathing  Pectus excavatum  Skin growths (freckles or moles)  Evidence of skin trauma (scar, laceration, or bruising) Inspected hands and fingernails 1 of 1 point Right: Appearance (1/4 point)  No visible abnormal findings  Redness  Moles or skin tags  Masses (warts, cysts, or tumors)  Freckles, birthmark, or other discoloration  Excessive dry or flaking skin  Purpura  Scarring  Laceration, lesion, or wound  Bruising  Rash Left: Appearance (1/4 point)  No visible abnormal findings  Redness  Moles or skin tags  Masses (warts, cysts, or tumors)  Freckles, birthmark, or other discoloration  Excessive dry or flaking skin  Purpura  Scarring  Laceration, lesion, or wound  Bruising  Rash Right: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Left: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Inspected lower extremities and toenails 1 of 1 point Right: Appearance (1/4 point)  No visible abnormal findings  Visible distortion or swelling  Brownish pigmentation  Skin thickening  Ulceration  Varicose veins Right: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Left: Appearance (1/4 point)  No visible abnormal findings  Visible distortion or swelling  Brownish pigmentation  Skin thickening  Ulceration  Varicose veins Left: Nail Changes (1/4 point)  No visible abnormal findings  Pallor  Cyanosis  Splinter hemorrhages  Clubbing Inspect lower extremities for edema 1 of 1 point Right: Edema (1/4 point)  No edema  Pitting  Non-pitting Right: Severity Of Edema (1/4 point)  No edema  1+ Slight pitting  2+ Deeper pit, disappears in 10 to 15 seconds  3+ Noticeably deep pit that lasts more than a minute  4+ Very deep pit that lasts 2 to 5 minutes Left: Edema (1/4 point)  No edema  Pitting  Non-pitting Left: Severity Of Edema (1/4 point)  No edema  1+ Slight pitting  2+ Deeper pit, disappears in 10 to 15 seconds  3+ Noticeably deep pit that lasts more than a minute  4+ Very deep pit that lasts 2 to 5 minutes Tested capillary refill time 1 of 1 point Fingers (1/2 point)  Less than 3 seconds  Greater than 3 seconds Toes (1/2 point)  Less than 3 seconds  Greater than 3 seconds Palpated carotid arteries 1 of 1 point Right: Vibration (1/4 point)  No thrill  Thrill Right: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse Left: Vibration (1/4 point)  No thrill  Thrill Left: Amplitude (1/4 point)  0 Absent  1+ Diminished or barely palpable  2+ Expected  3+ Increased  4+ Bounding pulse [Show More]